Go-live gone wrong

Though it seems that much of the healthcare industry is finally on board with making the transition from paper to digital records, the transformation comes with a high price. Much anticipated, and sometimes hyped, electronic health record system rollouts cost millions of dollars and often end up causing chaos, frustration, even firings at hospitals across the country.

Case in point: Maine Medical Center in Portland, Maine, a 600-bed hospital that is home to the celebrated Barbara Bush Children’s Hospital, and a part of the MaineHealth network.

Maine Med’s go-live last December of its estimated $160 million Epic EHR system seemed at first to go off without a hitch. But four months later, the hospital network’s CIO, Barry Blumenfeld, MD, was out of a job, and, in an April 24 letter to employees, Maine Medical Center President and CEO Richard W. Petersen announced a hiring freeze, a travel freeze – and a delay in the further rollout of the EHR throughout the rest of MaineHealth.

The letter, obtained by Healthcare IT News, cited a $13.4 million operating loss the hospital sustained over six months of its fiscal year. Petersen cited as contributing to the loss a decline in patient volumes, the increasing number of patients who can't afford to pay for their care – and the launch of the electronic health record system.

"The launch of the shared electronic health record has had some unintended financial consequences," Petersen wrote."While there have been many advantages in the implementation of SeHR, in some cases, we've been unable to accurately charge for the services we provide. This lack of charge capture is hurting our financial picture."

"Since Epic's gone live, essentially, the Epic people failed to mention – and certainly, 100 percent failed to teach – that the nurses and the doctors were supposed to be somehow charging people for everything that we do," she added. "I guess we didn't know that Epic was supposed to be charging as we went along. Let's say I document that I put in an IV in – there goes a charge right there. That's how they get charged for that. The nurse puts in the IV, and then they put in the computer that they've done that. There's supposed to be a charge for that. So I guess, early after go-live, finance people were saying, 'Something's wrong; we're not charging.' But we didn't realize that we were the ones who were supposed to be charging, and we actually weren't taught how to charge. Not only that, but we weren't taught what was important to charge. We were basically taught how to navigate the right screens."

Now the clinicians are supposed to be charging, the nurse said, but they have not been taught anything different. "We haven't been brought back into a classroom and told this is how you're supposed to be doing it," she said. "We were never told that we would be responsible for putting those charges through."

'We have to pass at this time'
To follow up on the news story about MaineHealth's troubles, which Healthcare IT News posted on its website May 2, we contacted the communications department at Maine Medical Center May 3 and asked to arrange an interview with then Chief Information Officer Barry Blumenfeld, MD.

The response via email: "Barry has left the organization. We have an interim CIO ... let me see if he's available." A series of emails followed back and forth. Maine Medical Center asked for the questions in order to find the right person for the interview. Healthcare IT News supplied them. The emails from Maine Med ended with this one, on May 30:

"Sorry, but we have to pass at this time, as our team is really focusing on follow-up work related to the rollout. Can we check-in later this summer to see if that would be better timing? Thanks, and sorry to take so long with a response."

On May 22, we emailed Blumenfeld directly to ask for an interview. "I would love to speak with you," he wrote. "I've thought (about) my experiences and believe that I have some things to say that would be of value to your audience. However, I'd like to let MaineHealth know that I will be talking with you before I do it. I’ve sent them a note giving them the heads up and asking if they have any specific concerns – and will let you know just as soon as I hear back."

A day later, Blumenfeld said in an email he would have to pass on the interview.

Epic, meanwhile, also declined an interview request. A spokesperson told Healthcare IT News that, "Only MaineHealth can share information about their system.

"Since each system is configured for their needs, many things are customized."

Not alone to decline
Maine Medical Center was not alone in taking a pass on an interview about its rollout. At 885-bed Wake Forest Baptist Medical Center in Winston-Salem, N.C., a media contact said, "We are not facilitating media interviews at this time."

Sheila Sanders, Wake Forest's CIO, planned to resign at the end of May, according to a May 17 article in the Winston-Salem Journal.

"The health system has struggled with the implementation of Epic, a new electronic medical records system," the Journal reported. "However, health system officials said Sanders' resignation was not related to Epic and that Sanders is relocating to Florida to spend more time with family."

Partners HealthCare in Boston, an eight-hospital system with some elite names – Massachusetts General and Brigham & Women's, to name two – made its plans for an Epic rollout known last year. But it too declined a June 3 request for an interview with Healthcare IT News, saying: "Given that we are so very early in our effort, we are going to pass on this opportunity. At this point in this very early stage, we would be unable to effectively answer these questions. We are years away from go-live dates. Thanks for thinking of us, and do not hesitate to check in, as we get further along in our process."

Financial stress
The Winston-Salem Journal reported that Wake Forest had launched another round of "multi-million dollar" cost-cutting measures that would last through at least June 30, the end of its 2012-13 fiscal year, related to "fixing Epic revenue issues."

Those measures include attempts at volunteer employee furloughs and hour-and-wage reductions, a hiring freeze, a reduction in employer retirement contributions, and elimination of executive incentive bonuses for 2013.

The Journal added that Wake Forest Baptist cited $8 million in "other Epic-related implementation expense" that it listed among “business-cycle disruptions (that) have had a greater-than-anticipated impact on volumes and productivity." Also listed was $26.6 million in lost margin "due to interim volume disruptions during initial go-live and post go-live optimization."

Wake Forest Baptist attributes some of its operating loss in its current fiscal year to projected revenue that has been delayed related to problems rolling out Epic, particularly with billing, procedure coding and collections.

Detroit-based Henry Ford Health System, meanwhile, reported total revenues of $4.46 billion in 2012, an increase of $490 million from the $3.97 billion total revenues in 2011. Overall, however, Henry Ford reported $53.1 million net income for 2012, as compared to $62.9 million in 2011 – a decrease of 15 percent.

"The net income decrease is related to two factors," Henry Ford's Chief Financial Officer James Connelly noted in an April 25 news release. "The first is an increase in uncompensated care in 2012 for the health system. Second, Henry Ford is making a significant investment in state-of-the-art information technology in our clinical, business and insurance operations, which positions us well for healthcare reform."

"It's a large number," Henry Ford CIO Mary Alice Annecharico acknowledged in a recent interview with Healthcare IT News, about the health system's more than $350 million EHR initiative. Annecharico went on to say that Henry Ford chose not to float bonds or borrow for the project, but rather to use operating capital to implement the system. "That means we chose not to do other things," she said. "That means we chose not to build and acquire new organizations that would have a very large capital investment while we're putting this system in."

She said it was a decision supported by leadership and endorsed by the board. "We want to be able to serve the community, and this is the grounding platform for us being able to do that," she said.

As Edmund Billings, MD, sees it, the amount of money and complexity that goes into these types of implementations is not right for mid-sized health systems. Kaiser and Partners might be able to afford these massive EHR rollouts, but smaller health systems struggle.

Billings, who serves as CMIO of Medsphere Systems, which markets OpenVista, an open-source EHR model that has its roots in the VA's VistA technology, admits to a certain bias toward an open approach.

"I believe that the single source, proprietary, milk-'em-dry model is going to hit a wall," he told Healthcare IT News. "Particularly when the organizations are not going to be able to go fee-for-service to cover it, or they don't have the endowment."

Going live
Kaveh Safavi, MD, (pictured at left) who leads the health industry business for North America for Accenture, a global consulting and outsourcing firm, says Accenture tends to serve very complex, very large systems. Lately, Accenture has worked mostly on Epic and Cerner implementations, but its consultants have also worked on deploying Allscripts and Meditech.

"The general rule of thumb," he says, "is whatever you spend on your technology, you're going to spend twice as much on the task of implementation."

"What is often described as a 'glitch,'" he said, "could be a glitch at the level of technology implementation, but it's often at the level of the processes themselves. So translating business rules into technology rules … it's not really a technology problem, but the technology has to catch it."

Most organizations change their revenue cycle system either ahead or at the same time they deploy a new EHR, he said. "Because there's such a close tie between diagnoses and procedures and charges and bills, they're often linked together. Now, one may precede the other, but many organizations are often making a decision, which requires a substantial change if not a complete replacement of the revenue or billing cycle process ahead of the electronic medical record at the same time, or sometimes close to it."

As Safavi sees it, "The harder work is more in the process than in the technology configuration. There's more technology, actually on the process side than on the technology side."

Devore Culver, (pictured at right) executive director and CEO of HealthInfoNet, Maine's health information exchange, agrees. He doesn't know what the problems were at Maine Medical Center, but as former CIO at Eastern Maine Healthcare and in previous roles at Eclipsys and Cerner, he knows a thing or two about implementations.

"Large implementations frequently go weird places," he said. "Usually a couple things are at the core, one is you don't fully understand the implications for workflow. When you finally get it turned on, you find out that either you didn't entertain certain aspects of workflow as part of what the software could or couldn't do. Or perhaps, as important – and I've had this happen to me twice in my life – you don't fully understand the ramifications of a front-end implementation on back-end systems."

"When I put in my first patient clinical system in 1996, we had a little bump in accounts receivables for a few months," he admitted. "It wasn't outrageous, but it clearly was a factor. You just work through the mappings until you figure out what you missed. That's the problem with these complex structures. You don't always know what you're getting into until you get into it."

Safavi pointed out that large EHR deployments are much more common today. "It's a different conversation than it was 10 years ago," he said. "There used to be a big debate about whether you implement these things incrementally or whether you implement them across an enterprise in a much more rapid fashion – the so-called big bang."

Meaningful use has driven some of that approach, he said, and processes have been better developed on how to roll out on a much larger scale.

"Where you often see organizations struggle is when they're a little bit resource-constrained, and they can't actually invest in the process improvement and the process redesign necessary up front, but they're still committed to a big bang implementation, but they just haven't done the prep work," said Safavi.

Meaningful use puts some pressure on a number of aspects of implementation, he said. Organizations can't just deploy an EHR; they have to make sure it is configured to exchange information. That introduces another technology, which adds to the complexity. There's also the patient engagement piece of meaningful use: "Now they're all under pressure to figure out how to get some level of patient interaction."

Safavi said there are no "catastrophic" rollout failures today – not since the infamous $34 million Cedars Sinai breakdown of a decade ago, at least.
"It's much more about (the fact that) this is hard work; it takes a long time; everybody gets through it," he said. "There're no real options to avoid it. It's not the core technologies that are the problem. It's how we interact with it."

Jim Turnbull, CIO at Salt Lake City-based University of Utah Healthcare, said he had been able to avoid the pressure of meaningful use.

"My last two employers have done (or are in the midst of) Epic rollouts from revenue cycle through EMR/CPOE, "he said. "We've been lucky to roll these out in a staged manner over a period of several years, without a lot of MU pressure on the accelerator."

This has helped to protect the organizations financially, and not expose them to the inherent risks that come with a big bang.

The first rollout – at the Children's Hospital in Denver – was in the early years of Epic's entry into the inpatient market space, from roughly 2003 to 2006. The current rollout started in 2009 and will conclude with the replacement of the major inpatient applications this year.

"In hindsight, I guess we are always reminded that these are complex endeavors, and that the process and culture change is much more significant than the technical challenge," Turnbull said. "Another thing that still seems common in the industry is that EMR projects are considered 'IT projects.' As we know, they are anything but!"

Back to Maine Medical Center
Accenture's Safavi says he's not familiar with the circumstances at Maine Medical Center. However, it's not uncommon, he said, for the IT team to suffer fallout from an implementation that does not go off as expected.

"Lots of things can happen, but the most common is surprise," he said. "It generally exposes an organization around either lack of planning or a cultural issue. You often see the IT organization want to go faster than the clinical organization, and the clinical organization will be unprepared or unwilling."

Those cases create a difficult problem for leadership and boards, who face answering, "What is more important here? Is it managing the pace and cooperation of our stakeholders, or is it managing the economic cost of the transition?"

"That's the job of boards and leaders to figure out," said Safavi. "There's no one answer. Every answer varies with the organization."

It made sense to select Epic for inpatient care, MaineHealth's Blumenfeld, told me in 2010. The Epic EHR was then already rolling out at MaineHealth's owned and affiliated medical practices.

Rather than a best-of-breed approach that many CIOs espoused in years past, most now see more merit in a single vendor approach. Blumenfeld is among them. "The end user interface stays consistent across all venues including ambulatory and inpatient, and the information that's in the repository is integrated in a way that only a single database can do," he explained.

The goal, said Blumenfeld, is to have a more integrated workflow, a more integrated presentation and more integrated data set.

"This also helps, by the way, when we start to talk about measuring the quality that we deliver and population health efforts – making sure people get their flu shot or making sure everyone gets aspirin after a myocardial infarction," he said. "Those things are greatly aided by our ability to capture all the data in one big bucket and then analyze it to improve the care we deliver."

"We found that Epic has a great reputation and ranks high on things like the KLAS rating and generally receives very high marks from the other systems that have adopted them in recent years," Blumenfeld said.

A couple of years later, when he and his team were preparing for the rollout at Maine Medical Center, he said Epic was enjoying so much popularity because, unlike other EHR companies, Epic had grown, but not through acquisition, thereby avoiding the integration problems that often come with patching disparate systems together.

When Blumenfeld spoke with Healthcare IT News Associate Editor Erin McCann a couple weeks prior to the scheduled Dec. 1, 2012, rollout at Maine Med, he brought up the famous Gartner curve.

"You know where you start out and everyone's very excited, and you go for a week or two: 'This is great; this is really cool,'" he said. "Then you start to notice all the problems, and you fall into the valley of despair. That usually happens a month or two into the project.

"Then by three or four months, you're coming out of the valley of despair, and people are starting to say, 'Wow, this is OK, you know, I can live with this.' Then by seven or eight months, it's, 'Wow, I don't know why I ever didn't live with this.' That's when you start getting the real benefits of an electronic health record."

The Maine Medical Center nurse who spoke with us about charge capture issues is still waiting to see those benefits. Meanwhile, she said, she is concerned about best practices and lack of training.

Most nurses had three four-hour courses, with some specialty nurses getting an extra course. Some of the courses were led by Epic employees, but most were by nurses taken off the floor, trained on the system and then sent back to teach the other nurses.

"It didn't follow a workflow at all," she said. "It was really sort of patchwork." Moreover, she said, when people had questions about the workflow, they really weren't addressed. "I felt we were not educated well at all. When we actually went live, it was scary. People did not know what they were doing."

The nurses did not know how to enter orders appropriately. "There were huge gaps of people not knowing how to put orders in and not knowing how to do really important things like blood administration, how to order the blood. We were never taught any of those things."

Nurses have learned how to do some of those entries by now, she said, but there are so many ways to do the exact same things.

"One person will show you one thing; another person will show you something different," she said. "There're eight different ways to do the same thing. Every day, you feel like, 'I don't know if I did this admission right; I don't know if I entered any of my documentation right. There's a lot of discrepancy in how we were taught to document."

"The change is a wrenching one," Blumenfeld told Healthcare IT News in that interview before the rollout this past December. "It's wrenching for the physicians, it's wrenching for the nurses and it's wrenching for the support staff, the financial people, the operations people. Everyone has to do things differently than they did before. So it's a big, big change for any hospital to go to an EHR."

Healthcare IT News Managing Editor Mike Miliard and Associate Editor Erin McCann contributed to this story.It was first published in the July 2013 print issue.